Provider Demographics
NPI:1750468922
Name:ROACH, SHERENE ANDREA (ARNP)
Entity type:Individual
Prefix:
First Name:SHERENE
Middle Name:ANDREA
Last Name:ROACH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 VILLAGE TRL APT 1-205
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9383
Mailing Address - Country:US
Mailing Address - Phone:386-453-6490
Mailing Address - Fax:
Practice Address - Street 1:1190 N STONE ST
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-2511
Practice Address - Country:US
Practice Address - Phone:386-738-1792
Practice Address - Fax:386-738-4865
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2994522363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305843300Medicaid